If there is anything that is a measure of the Academy of Breastfeeding Medicine’s (ABM’s) relevance and importance, it is its series of Clinical Protocols in general and the publication in this issue of Breastfeeding Medicine of its latest protocol,1 entitled “Breastfeeding-Friendly Physician’s Office,” in particular. To remind those who have forgotten and to inform those not in the know, these protocols have been formally accepted for distribution by the National Guideline Clearinghouse (www.guideline.gov) of the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services under its mandate to provide a “public resource for evidence based clinical practice guidelines.” No less a testimony to the quality of these protocols and their acceptance as a standard has been the pronouncement in the most recent Policy Statement on “Breastfeeding and the Use of Human Milk”2 by the Section of Breastfeeding of the American Academy of Pediatrics that “evidence-based protocols from organizations such as the Academy of Breastfeeding Medicine provide detailed clinical guidance for management of specific issues,” and thus there is no need for the American Academy of Pediatrics to duplicate clinical management protocols.

So what is so special regarding the latest ABM protocol, which on the surface seems to discuss a relatively mundane issue of creating a practice environment that is supportive of breastfeeding, but does not address a clinical issue that might help the physician in the management of a specific maternal–infant dyad? From my perspective it is just this focus that makes this a most important and, I would venture to say, almost revolutionary document.

For one, it acknowledges that from a public health point of view the major problem in our breastfeeding programs is not the breastfeeding initiation rate but rather the precipitous drop in the breastfeeding rates after discharge from the hospital, the all too short duration of any breastfeeding, let alone the rate of exclusively feeding human milk. (As a reminder, in the United States the averaged initiation rates are over 75%, whereas the “any” breastfeeding rate at 6 months is 44%, and the rate for exclusivity of breastfeeding is 33% at 3 months and only 14% at 6 months, with even lower rates for minority mothers, particularly those of color.)

The “success” of the initiation rates reflects hospital-based public health policies that are best exemplified by the incorporation of the World Health Organization/UNICEF 10 Steps into hospital routines, the Baby-Friendly Initiative, and the decision of the Joint Commission to include the exclusive breastfeeding rate as a Perinatal Core Measure in their assessment of hospital performance and quality. As such, it has become increasingly clear that it is just such successful public health population-based, system-oriented approaches that need to be formulated and standardized for the post-hospital period if we wish to extend the success on initiation beyond the immediate postpartum period into the critical months of early infancy and beyond.

Thus, the evidence-based recommendations that are detailed in this latest ABM protocol are not just welcome but are a major conceptual contribution that will, it is hoped, facilitate the refocusing our efforts and the direction for the investment of resources that will result in maximum public health benefit. As I have mentioned previously, we need to go beyond the management of the individual maternal–infant dyad and create supportive, culturally sensitive, total environments for the support of breastfeeding. That this environment must be “total” and not just a reflection of the individual caretaker’s knowledge or skills is emphasized by the detailed outline in the Protocol of what is necessary to truly become a Breastfeeding-Friendly office.

Most important is the need for the office environment to implement the World Health Organization’s International Code for Marketing of Breast-milk Substitutes regarding use of noncommercial educational material and limiting the visibility of human milk substitutes so as to demonstrate breastfeeding support. In addition, the entire medical, nursing, technical, and administrative staff of the office need be properly trained in their appropriate roles so as to provide a uniform supportive environment. Furthermore, the physician and his or her team must link with other community-based programs while serving as a public advocate for breastfeeding. To paraphrase the well-used dictum “it takes a village to raise a child,”3 and, no less so, it has become increasingly clear that it takes more than the individual health practitioner working in a vacuum to succeed in increasing our breastfeeding rates.

No less important is the fact that this protocol truly reflects the international mission of the ABM. Not only do the recommendations avoid the trap of being too United States–centric, on the contrary, they reflect the reality of the varied healthcare systems and practices that exist worldwide, be it in the length of the postpartum stay in the hospital, the roles of the non-physician provider, patterns of financial compensation and insurance payments for breastfeeding support services, role of family physician versus pediatrician, etc. One need just peruse the reference list to note that this document1 will truly serve the international audience of ABM.

Thus, the ABM Protocol Committee should be thanked and congratulated for producing this vitally needed document and refocusing our energies for the greater good.